CQC report explained · a residential care home
What the CQC found at Talbot House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks were not fully assessed or explained in care plans. Inspectors found 19 medicine errors over two months, including incorrect administration and poor records.
- Effective?
- Requires improvement
- Some staff lacked a full understanding of eating disorders, autism and abuse awareness. Inspectors found that there were not enough suitably trained, skilled and experienced staff on every shift.
- Caring?
- Good
- People said staff were kind, respectful and approachable. People were involved in care planning, and relatives were included when the person consented.
- Responsive?
- Requires improvement
- Care plans were individualised but did not always explain goals, progress, preferences or support clearly. People also said there was not much to do during evenings and weekends.
- Well-led?
- Requires improvement
- The registered manager did not have effective oversight or quality checks. Staff roles were unclear in the manager’s absence, and staff did not always feel supported or listened to.
What inspectors found, December 2022
Talbot House was rated Requires Improvement; inspectors found kind, specialist care but serious problems with medicines, risk records, staff training and management oversight.
This was the home’s first inspection. Inspectors visited on 27 October 2022 and reviewed information until 18 November 2022. They spoke with people living there, relatives, staff and professionals, and checked care records, staff files and other documents.
The home supports up to seven people with eating disorders. People said staff were kind, listened to them and helped them feel safe. Inspectors also found good access to health professionals, clean and well-maintained surroundings, and support that helped people move towards greater independence.
However, inspectors found important safety and management weaknesses. There were 19 medicine errors over two months, some risks were not fully assessed, records were inconsistent, and some staff did not understand eating disorders, autism or abuse well enough. Care goals and end-of-life wishes were also not always clearly recorded.
The overall rating Requires Improvement means the home was not consistently providing safe, effective, responsive or well-led care. Caring was rated Good. The provider was asked to send an action plan, and CQC said it would monitor progress.
Kind and respectful staff
People said staff treated them with kindness and listened to them. Inspectors found that people were involved in decisions about their care.
“People told us the staff treated them with kindness.” from the report
Specialist health support
The home worked with mental health and physical health professionals. It also provided access to dietitian, occupational therapy, art and drama therapy support.
“People were supported to access all relevant health professionals in order to support their recovery” from the report
Positive care outcomes
People were supported to build independence and take gradual steps towards healthier lifestyles and community living.
“The service produced positive care outcomes.” from the report
Clean and maintained home
Inspectors found the home clean, tidy and well maintained, with communal areas and private bedrooms available.
“The service was well maintained, clean and tidy.” from the report
Medicine errors
seriousInspectors found 19 medicine errors over two months. These included incorrect administration, incorrect stock counts and incomplete medicine records.
“Over a period of two months we identified records showing 19 medicine errors.” from the report
Risks not fully assessed
seriousSome important risks did not have clear guidance for staff, including PEG feeding, road safety, sensory overload and taking medicines during family visits.
“Not all risks to people had been fully explored and therefore there was a lack of clear guidance for staff about how to reduce the risks.” from the report
Staff training and support
needs fixingSome staff did not understand eating disorders, autism or abuse awareness well enough. Some staff also said they did not receive regular supervision or feel listened to.
“Some staff we spoke with did not have a full understanding of the risks relating to eating disorders” from the report
Weak management checks
seriousThe home did not have effective quality assurance systems. The manager had not identified several problems with medicines, staffing, risk management and records.
“There were no overarching quality assurance systems in place to enable them to effectively assess and be aware of all concerns” from the report
Care plans lacked detail
needs fixingSome goals, preferences and end-of-life wishes were not fully explored or recorded. This could lead to inconsistent support.
“The provider had failed to ensure that people's preferences had been fully explored and recorded in relation to goals, needs and end of life wishes.” from the report
- 01What changes have been made to prevent further medicine errors, and how are medicine records now checked?
- 02How are PEG feeding, sensory needs, road safety and medicines during family visits assessed and explained to staff?
- 03What training have all staff completed on eating disorders, autism and safeguarding?
- 04How often does the registered manager now audit medicines, care records, staffing and risks?
- 05How are people’s goals, activities, preferences and end-of-life wishes recorded and reviewed?
This was the first comprehensive inspection of the newly registered home, covering all five key questions; infection prevention and control was also checked under Safe. This explanation was written from the published report of 7 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Talbot House
Each visit the CQC has published, newest first, back to the day the home was registered.
- December 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2021
Registered with the Care Quality Commission on 14 July 2021.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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